Service Agreement Performance Framework

Transcription

1 June Service Agreement Performance Framework Activity Based Funding and Management

2 Contents 1 Background 4 Overview of the Department s Performance Framework 4 2 Purpose of the Service Agreement Performance Framework 6 3 Service Agreement Performance Monitoring and Reporting Process 7 Service Agreement Performance Monitoring 7 Exceptional Events 7 Service Agreement Performance Reporting 7 Service Agreement Quarterly Performance Review Meetings Changes to KPIs 9 New KPIs 9 Changes to Existing KPIs 9 Removal of KPIs 9 5 Service Agreement Performance Management Process 10 Principles of the Service Agreement Performance Management Process 10 Elements of Service Agreement Performance Management 11 Performance Intervention Levels Key Performance Indicators Data Summary 15 7 Service Agreement Key Performance Indicator s 19 Finance and Activity 19 Variation from budget full year projected FA1 19 THS cash liquidity FA2 19 Acute admitted raw separations FA3 20 Acute admitted inlier weighted units (same day and multi day) FA4 20 Admitted patient episode coding (clinical coding) including contracted care timeliness FA5 21 Admitted patient episode coding (clinical coding) including contracted care accuracy FA6 22 Safety and Quality 23 Hand Hygiene compliance SQ1 23 Healthcare associated staphylococcus aureus (including MRSA) bacteraemia infection rate SQ2 23 Access to Care (Emergency Care and Elective Surgery) 24 Percentage of Triage 1 emergency department presentations seen within the recommended time AEC1 24 Percentage of Triage 2 emergency department presentations seen within the recommended time AEC2 25 2

3 Percentage of emergency department did not wait presentations AEC3 26 Time until most admitted patients (90%) departed emergency department AEC4 27 Ambulance offload delay part 1 AEC5 28 Ambulance offload delay part 2 AEC6 28 Access to Elective Surgery 29 Baseline elective surgery admissions AES1a 29 Rebuilding Health Services AES1b 30 Tasmanian Health Assistant Package admissions AES1c 30 Average overdue days AES2 30 Maximum wait time AES3 31 Category 1 admitted within the recommended time AES4 31 Category 2 admitted within the recommended time AES5 32 Category 3 admitted within the recommended time AES6 32 Category 2 treat in turn rates AES7 33 Category 3 treat in turn rates AES8 33 Hospital initiated postponements (HIPs) AES9 34 Mental Health Day re-admission rate MH1 34 Acute 7 day post discharge community care MH2 35 Seclusion rates MH3 36 Primary Health 37 Priority category one Aged Care Team (ACAT) clients seen on time in all settings PH1 37 Priority category two Aged Care Team (ACAT) clients seen on time in all settings PH2 37 Priority category three Aged Care Team (ACAT) clients seen on time in all settings PH3 38 Oral Health 38 Number of Dental Weighted Activity Units (DWAUs) delivered between 1 July 2015 and 30 June 2016 OH1 38 Proportion of Emergency clients managed on the same day as they are triaged OH2 39 Cancer Screening and Control Services 40 Percentage of clients assessed within 28 days of screening mammogram CSCS1 40 Eligible women screened for breast cancer CSCS2 40 3

4 Background 1 Background Overview of the Department s Performance Framework Under the Tasmanian Health Organisations Act 2011 (the Act), the Minster for Health (the Minister) enters into annual Service Agreements with THO Governing Councils. The development of, and advice regarding these Agreements originates from the Department (acting on behalf of the Minister as the Purchaser). The Department s purchasing function is supported by a number of governing instruments, including the Purchasing Framework, which outlines the process followed in purchasing services, and this document, the Service Agreement Performance Framework, which codifies the process of monitoring THS against the requirements of the Service Agreement. In addition to its role as the Purchaser, the Department has a broader responsibility as System Manager to undertake such strategic, planning and monitoring functions and activities as necessary to enable it to provide assurance to the responsible Ministers (the Minister for Health and the Treasurer have joint responsibilities under the Act) that the Tasmanian health system is being managed effectively and efficiently. There are many activities that occur in the Tasmanian health system, outside of those that are purchased directly from the THS through the Service Agreement that should be subject to ongoing monitoring. The Monitoring Suite, governed by the Monitoring Suite Operational Guidelines, enables the System Manager to gain an understanding of the state of Tasmania s publicly funded health services, supplementing the quasi contractual arrangements of the Service Agreement. Should there be a patient safety issue that requires an urgent response, it will be guided by the Clinical Governance Framework. The functions of Purchaser and System Manager cannot be viewed in isolation of each other - the nature and volume of services purchased will impact on the effectiveness and efficiency of the Tasmanian health system and the primary mechanism for effective system management is through informed, appropriate purchasing. Purchasing is a necessarily transactional process, and so must be contextualised to be effective as a mechanism to enact Government policy in health and to ensure that purchasing decisions reflect the longer term application of strategy. An annual (rolling) Statement of Purchaser Intent (currently under review as part of the One Health System reform programme), which signals purchaser intentions over the coming five years, will act as the bridge between the functions of the Purchaser and System Manager. This will be the translational implement linking the activities of the Purchaser to the priorities of the System Manager and will be released in the first quarter of every calendar year. The dual role of the Department as both Purchaser and System Manager is represented graphically in Figure1. 4

5 Background Figure 1: Inter-relationship of compliance and monitoring. 5

6 Purpose of the Service Agreement Performance Framework 2 Purpose of the Service Agreement Performance Framework Annual Service Agreements between the Minister and THS Governing Council sets out the expectations of the volume and quality of services to be delivered and the funding provided in relation to the delivery of those services. It is the responsibility of the Governing Council to ensure that the THS deliver the requirements of the Service Agreement once established. It is the responsibility of the Department to ensure that THS against those requirements is monitored and managed to ensure that where necessary, the intervention options available to the Minister under the Act are effectively implemented. The Service Agreement Performance Framework explains the process of monitoring THS against the requirements of the Service Agreement to ensure that where determined necessary, the management options available to the Minister under the Act are effectively implemented. It describes an integrated process for the monitoring and assessment of THS against the requirements of the Service Agreement and provides both the Department and the THS with a clear delineation of roles, responsibilities and expectations in response to identified Service Agreement issues. It should be read in conjunction with the following key documents: THS Service Agreement State-wide Clinical Governance Framework THS Purchasing & Funding Guidelines. In addition, a number of key system management frameworks have been committed to under the One State, One Health System; Better Outcomes reform programme. These include: Statement of Purchaser Intent Monitoring Suite of Indicators Health Services Regulation Management Guide 6

7 Service Agreement Performance Monitoring and Reporting Process 3 Service Agreement Performance Monitoring and Reporting Process Service Agreement Performance Monitoring The Annual Service Agreement between the Minister and THS Governing Council includes specific KPIs and associated targets. KPIs and targets are systematically considered and adopted in the following order of preference where practical: existing national policy based targets existing Tasmanian health policy based targets new targets based on previous baselines. s establish the s of that determine whether any action is required regarding the identification and management of Service Agreement issues. Not all national or state based targets form part of the Service Agreement. Some have been determined as better placed within the Monitoring Suite as broader markers of the effective and efficient management of the Tasmanian health system. Further information regarding the target is provided in section 6. Exceptional Events There may be circumstances beyond the reasonable control of the THS which may prevent the achievement of s and it is important that such circumstances are recognised. At its discretion, and on a case-by-case basis, the Department will consider requests from the THS to consider such circumstances as part of the ongoing monitoring process. The intention is to recognise extraordinary and generally unforseen events beyond the reasonable control of the THS, but not planned service interruptions such as capital works or ad hoc operational difficulties. The THS is expected to provide the Department with timely advice of such circumstances and to actively mitigate any risk(s) to achieving s. Service Agreement Performance Reporting At the end of each quarter, the Department provides the responsible Ministers with the THS Quarterly Service Agreement Performance Report, outlining Service Agreement against all KPIs over the preceding quarter and, where necessary, recommended interventions. The report is compiled by the System Purchasing and Performance (SPP) Unit of the Department following completion of quarterly Service Agreement review meetings with the THS. 7

8 Service Agreement Performance Monitoring and Reporting Process Service Agreement Quarterly Performance Review Meetings Quarterly review meetings are co-ordinated by SPP. Meetings are characterised by: a common standard agenda for all meetings, varied for specific local issues and the escalation status THS led discussion that enables THS representatives to describe their proactive management from an operational- perspective aiming to reduce the need for further escalation of the response clear recording and communication of actions and requirements of the THS and the Department. Core attendance is kept to a minimum to facilitate smooth and efficient conduct of business ensuring coverage of each domain. Additional attendees may be included where attention to specific areas of requires the involvement of staff with specialist expertise and knowledge. Each meeting will have the following core attendees: The Department: SPP Deputy Secretary will attend all meetings other Departmental Directors or their representatives will attend as required generally, representatives of SPP will also attend and provide secretariat support if required. THS: the attendance of the THS Chair is required attendance by other members of the Governing Council and/or senior executives is at the discretion of the Chair, unless attendance of a specified executive is requested by the Secretary or delegate. It is anticipated that the THS Chief Executive Officer will attend. The Secretary of the Department may attend if and when a issue has been escalated and is unsatisfactory. 8

9 Changes to KPIs Changes to KPIs New KPIs Access to Care (Emergency Care and Elective) Baseline elective surgery admissions - ( based on whole of THS) Average overdue days Maximum wait time Category 2 admitted within the recommended time Category 3 admitted within the recommended time Category 2 treat in turn rates Category 3 treat in turn rates Hospital initiated postponements (HIPs) Cancer Screening and Control Services Percentage of clients assessed within 28 days of screening mammogram Eligible women screened for breast cancer Changes to Existing KPIs Finance and Activity Variation from budget full year projected ( based on whole of THS) THS cash liquidity ( based on whole of THS) Mental Health Service 28 Day Re-admission rate (Target reduced to </= 13.9%) Seclusion Rates (Target reduced to <8 per patient days) Oral Health Proportion of Emergency clients managed on the same day that they are triaged (Target increased to 80%) Primary Health Priority category one Aged Care Team (ACAT) clients seen on time in all settings ( based on whole of THS) Priority category two Aged Care Team (ACAT) clients seen on time in all settings ( based on whole of THS) Priority category three Aged Care Team (ACAT) clients seen on time in all settings ( based on whole of THS) Removal of KPIs Access to Care (Emergency Care and Elective) Percentage of all emergency department presentations seen within recommended triage time (removed from Service Agreement to be included in Monitoring Suite) 9

10 Service Agreement Performance Management Process 5 Service Agreement Performance Management Process Principles of the Service Agreement Performance Management Process The Department s approach to monitoring, assessment and response is shaped by the principles outlined in Table 1 below. Table 1: Principles of the Performance Framework Realistic Performance and funding expectations will be balanced with the res and capacity of the health system and the current fiscal environment. Consistency and Transparency The Department will apply a consistent and transparent method for assessing against clear, agreed s, and responding where appropriate. The default response to the non-achievement of targets will be escalation, with the Minister (or delegate) maintaining discretion to waive such escalations. Accountability The Department and THS have distinct and separate roles and accountabilities as Purchaser and Provider respectively. The Department, on behalf of the Minister, will negotiate an annual Service Agreement with the THS and monitor against the requirements of the Agreement. The THS is accountable for delivering services to the agreed standards outlined in the Service Agreement and ensuring that an effective internal framework is in place that demonstrates processes to actively monitor the requirements of the Agreement. Informed Purchasing The Department s System Manager role will inform the establishment of purchasing priorities and KPIs, in turn shaping negotiation of the Service Agreement. Integration The Department recognises change or variation in a particular aspect of may require changes to other, interdependent, elements of the system. The Department acknowledges that influences outside the control of the THS may affect and such factors will be considered when is assessed. Recognition Superior will be recognised and reviewed by the Department for lessons to be shared across the THS. 10

11 Service Agreement Performance Management Process Elements of Service Agreement Performance Management Service Agreement management will involve: on-going monitoring and review of THS against the requirements of the Service Agreement identifying a concern and determining the appropriate response determining when a intervention is necessary and the of intervention required determining when the intervention needs to be escalated or can be de-escalated. Performance Intervention Levels There are four s in the Service Agreement Performance Framework. The of response and intervention dictates the action required by the THS and/or the Department. The Minister approved delegation of certain Ministerial powers and functions that enables the Secretary to escalate or de-escalate concerns for: Level 1 (unsatisfactory ), requesting a Performance Improvement Plan Level 2 (sustained unsatisfactory ), ability to appoint a Performance Improvement Team. The Minister retains the power to appoint a Ministerial Representative to assist the Governing Council, if considered necessary, as part of a Level 2 Performance Escalation. The Minister also retains the power to approve a Level 3 Performance Escalation. The non-achievement of any individual Service Agreement will lead to the immediate identification of a concern and application of the intervention process outlined below. Service Agreement KPIs require compliance and the achievement of assigned targets within the specified assessment. Generally, a escalation will only be recommended in circumstances where the THS is unable to demonstrate to the Department that: the concern is being actively managed and monitored by the THS a robust and transparent plan for sustainable improvement is in place within the THS the THS possesses the necessary skills to achieve sustainable improvement in the area of concern. The Minister may waive any recommendation received from the Department to proceed with a escalation. Based on the response provided by the THS to concerns, an issue may be escalated or deescalated in a non-sequential fashion. Service Agreement KPIs are viewed independently of each other - that is, escalation or de-escalation is managed on the basis of each KPI, without mitigation by in other KPIs. Performance Escalation Level 0 (Satisfactory Performance) If a Service Agreement is achieved, the KPI will be assigned Level 0 (satisfactory ). Satisfactory will be noted in the THS Quarterly Service Agreement Performance Report provided to the Minister. Performance Escalation Level 1(Unsatisfactory Performance) The non-achievement of a Service Agreement will lead to the immediate identification of a concern and the application of the intervention process. In the event of non- 11

12 Service Agreement Performance Management Process achievement, the Secretary will consider escalating the issue to Level 1 (unsatisfactory ). Before taking this action, the Chair and CEO will be advised of the intention to escalate and be provided with an opportunity to provide more information to the Department in relation to the issue. In such circumstances the Chair or CEO must provide supporting information within 7 days from receipt of the request. Performance Escalation Level 2 (Sustained Unsatisfactory Performance) At Level 2, direct intervention will occur due to sustained unsatisfactory. Formal notification of the intention to escalate to Level 2 will be provided by the Secretary to the Chair and the CEO. Depending on the nature of the concern, at Level 2, the Secretary may appoint a Performance Improvement Team or the Minister may appoint a Ministerial Representative to assist the Governing Council in its oversight of the THS s functions. Performance Escalation Level 3 (Challenged and Failing) For sustained concerns that have not been resolved, the Secretary may recommend to the Minister that a higher of response be initiated (Level 3 challenged and failing). Formal notification of the intention to recommend to the Minister that escalation to Level 3 should occur will be provided by the Secretary to the Chair and the CEO. Table 2 summarises the escalation/de-escalation response process. Figure 2 demonstrates the escalation/de-escalation decision process. 12

13 Service Agreement Performance Management Process Table 2: Performance Escalation/De-escalation Response Framework Level of Response Point of Escalation Response Level 0 Satisfactory Performance No action required Not applicable. Satisfactory noted in monthly Service Agreement Performance Report. Performance that exceeds expectations recognised. Point of De-escalation Not applicable. THO Act reference Not applicable. Level 1 Unsatisfactory Performance Performance Improvement Plan (PIP) required Non-achievement of a Service Agreement KPI target. The Secretary formally requests the Governing Council to: o Provide a PIP for approval; o Comply with the requirements of the PIP, and o Meet with the Department to formally monitor the PIP. The Department prepares an Escalation Notice for the THS. The requirements of the PIP are met. Part 7, Division 3 (sections 60-62) Level 2 Sustained Unsatisfactory Performance Performance Improvement Team OR Appointment of a Ministerial Representative to assist the Governing Council. PIP targets are not achieved and the Department is of the opinion that the concern is unlikely to be resolved without: The involvement of a Performance Improvement Team OR The appointment of a ministerial representative to assist the Governing Council to improve. The Secretary will: o Formally notify the Governing Council that a Performance Improvement Team is to be appointed in respect of the THS. The THS will provide all reasonable assistance to the Performance Improvement Team OR o Recommend that the Minister give notice to the Governing Council of the appointment of a representative to the Governing Council. The instrument of appointment of the Ministerial Representative will specify the terms and conditions of the appointment. The for which the Performance Improvement Team was formed expires OR The terms and conditions of the ministerial representative s appointment have been met. Part 7, Division 4 and Division 5 (sections 63-68) Level 3 Challenged and failing Changes to the governance of the THS may be required The Department is of the opinion the Governing Council has ceased to perform satisfactorily and no other action may be taken other than to dissolve the Governing Council. The Secretary will recommend that the Minister appoint an administrator who has the functions and powers of the Governing Council. The and conditions specified in the administrator s instrument of appointment are complete. Part 7, Division 6 (sections 69-73) 13

14 Service Agreement Performance Management Process Figure 2: Performance Intervention Decision Process Regular monitoring and review No Performance concern identified Performance exceeded expectations Yes Performance recognition Assess severity of concern No Intervention required Yes Implement of escalation De-escalate of intervention No Performance concern persisting Yes Escalate of intervention 14

15 Key Performance Indicators Data Summary Key Performance Indicators Data Summary Domain Code Finance and Activity (FA) Source of KPI Target FA1 Variation from budget - full year projected DHHS-Budget and Finance FA2 Cash liquidity DHHS-Budget and Finance FA3 Acute admitted raw separations Tasmanian Activity Based Funding Model (DHHS SPP). Negotiated with THS. Recognises prevailing State Government policy directions Balanced budget THS Operating Account has a favourable balance FA4 Acute admitted inlier weighted units (same day and multi day) Tasmanian Activity Based Funding Model (DHHS SPP). Negotiated with THS. Recognises prevailing State Government policy directions FA5 FA6 Admitted patient episode coding (clinical coding) including contracted care - timeliness Admitted patient episode coding (clinical coding) including contracted care - accuracy DHHS (SPP) 100% within 42 days of separation DHHS (SPP) 100% within 30 days of advice from SPP Domain Code Safety and Quality (SQ) Source of KPI Target 15

16 Key Performance Indicators Data Summary SQ1 Hand Hygiene compliance ACSQHC 70% (all specified facilities) SQ2 Healthcare associated staphylococcus aureus (including MRSA) bacteraemia infection rate National Standard 2.0 per patient days (all specified facilities) Domain Code Access to Care (Emergency Care and Elective Surgery) Source of KPI Target Access to Emergency Care AEC1 Percentage of Triage 1 emergency department presentations seen within recommended time Australasian College for Emergency Medicine 100% (all specified facilities) AEC2 Percentage of Triage 2 emergency department presentations seen within recommended time Australasian College for Emergency Medicine 80% (all specified facilities) AEC3 Percentage of emergency department did not wait presentations DHHS (SPP) 5% (all specified facilities) AEC4 Time until most admitted patients (90%) departed emergency department National Health Performance Authority 8 hours (all specified facilities) AEC5 Ambulance offload delay part 1 Australasian College for Emergency Medicine 85% within 15 minutes (all specified facilities) AEC6 Ambulance offload delay part 2 Australasian College for Emergency Medicine 100% within 30 minutes (all specified facilities) Access to Elective Surgery AES 1a Baseline elective surgery admissions DHHS - SPP AES 1b Rebuilding Health Services DHHS - SPP AES 1c Tasmanian Health Assistance Package admissions DHHS - SPP

17 Key Performance Indicators Data Summary AES 2 Average overdue days DHHS SPP Dec 15: 177 Jun 16: 137 AES 3 Maximum wait time DHHS SPP Dec 15: 730 Jun 16: 600 AES 4 AES 5 AES 6 Category 1 admitted within the recommended time Category 2 admitted within the recommended time Category 3 admitted within the recommended time DHHS SPP Dec 15: 80% Jun 16: 90% DHHS SPP Dec 15: 60% Jun 16: 70% DHHS SPP Dec 15: 40% Jun 16: 45% AES 7 Category 2 treat in turn rates DHHS SPP Dec 15: 40% Jun 16: 45% AES 8 Category 3 treat in turn rates DHHS SPP Dec 15: 40% Jun 16: 45% AES 9 Hospital initiated postponements (HIPs) DHHS SPP Dec 15: 14.7% Jun 16: 12.6% Domain Code Mental Health (MH) Source of KPI Target MH1 28 Day re-admission rate NMDS 13.9% (all specified regions) MH2 Acute 7 day post discharge community care NMDS 75% (all specified regions) MH3 Seclusion rates To be included in NMDS < 8 per patient days (all specified regions) Domain Code Primary Health (PH) Source of KPI Target PH1 Aged Care Team (ACAT) - Priority Category one clients seen on time in all settings PH2 Aged Care Team (ACAT) - Priority Category two clients seen on time in all settings PH3 Aged Care Team (ACAT) - Priority Category three clients seen on time in all settings ACAP Minimum Data Set ACAP Minimum Data Set ACAP Minimum Data Set 85% 85% 85% Domain Code Oral Health (OH) Source of KPI Target 17

18 Key Performance Indicators Data Summary OH1 Number of Dental Weighted Activity Units (DWAUs) delivered between 20 December 2012 and 30 June 2015 NPA on Treating More Public Dental Patients Sep15: Dec15: Mar16: Jun16: OH2 Proportion of 'Emergency' clients managed on the same day that they are triaged THO South (OHST) 80% Domain Code Cancer Screening and Control Services (CSCS) Source of KPI Target CSCS1 Percentage of clients assessed within 28 days of screening mammogram TBC >90% CSCS2 Eligible women screened for breast cancer TBC Number of women screened YTD is more than same time two years ago The timeframes for are specified against each KPI in the following section (Service Agreement Key Performance Indicator s). 18

19 Service Agreement Key Performance Indicator s 7 Service Agreement Key Performance Indicator s Finance and Activity Variation from budget full year projected FA1 This KPI measures the variance between full year budget and full year projected actual on a cash basis for all funding types. Calculated by subtracting the full year projected cash forecast from the full year cash budget on an all funds basis including carry forwards. Balanced budget projected. DHHS Budget and Finance. Performance is assessed quarterly. data collection Monthly. Data Source Finance 1. THS cash liquidity FA2 data collection This KPI is a measure of the THS s capacity to meet its financial commitments when they fall due. If the THS is unable to meet its financial commitments within a given month, an advance of future funding is required to ensure the THS complies with Treasurer s Instruction (TI) 402. This KPI is an early KPI that there is the potential for a liquidity problem impacting on the THS s capacity to meet its financial commitments within the current financial year. Calculated by subtracting the total of the advance from the closing balance of the THS Operating Account at the end of the month to demonstrate what the unadjusted position would have been. THS Operating Account has a favourable balance. DHHS Budget and Finance. Performance is assessed quarterly. Monthly. In instances where the THS requires an advance of funds in one month, it will enable the THS to take corrective action in the following month(s) to return the THS Operating Account to a favourable balance. 19

20 Service Agreement Key Performance Indicator s Data Source Finance 1. Acute admitted raw separations FA3 This KPI measures the volume of raw separations. A raw separation is an episode of admitted patient care. Raw separations are not adjusted for the complexity of the episode of care and represent each individual episode of care in a given. The total number of raw separations (admitted acute inc. qualified newborns and mental health) as defined in the DHHS Admission and Discharge Policy Manual effective as from 1 July This KPI measures baseline activity only. It excludes above baseline activity associated with, and funded under, separate Commonwealth or State programs data collection Tasmanian Funding Model - DHHS SPP. Performance is assessed quarterly on a year to date basis. Monthly. Data collected through Health Central from ipm on the sixth working day of the month. ipm. Acute admitted inlier weighted units (same day and multi day) FA4 This KPI measures the volume of inlier weighted units. Inlier weighted units are raw separations adjusted for the complexity of each individual episode of care. Previously measured as weighted separations, inlier weighted units are now a specified output of the Tasmanian Funding Model. 20

21 Service Agreement Key Performance Indicator s The total number of inlier weighted units (admitted acute inc. qualified newborns and mental health) as defined in the DHHS Admission and Discharge Policy Manual effective as from 1 July The average cost weight used to construct this KPI is calculated from the National Hospital Morbidity Database, using AR-DRG public cost weights published by the Commonwealth Department of Health and Ageing. However, the following costs are excluded as the Tasmanian Funding Model funds these separately (with the exception of depreciation which is not funded): Depreciation ICU Mechanical ventilation ED This KPI measures baseline activity only. It excludes above baseline activity associated with, and funded under, separate Commonwealth or State programs data collection Tasmanian Funding Model - DHHS SPP. Performance is assessed quarterly on a year to date basis. Monthly. Data collected through Health Central from ipm on the sixth working day of the month. ipm. Admitted patient episode coding (clinical coding) including contracted care timeliness FA5 This KPI measures the percentage of admitted patient episodes coded within 42 days of the episode separation. All admitted patient episode separations within the specified assessment are within scope. The coding date (considered to be the date recorded against the principal diagnosis field in ipm) will be compared with the separation date. All records not coded within 42 days of the separation date will be considered to fail. 100% within 42 days of separation. DHHS SPP. Quarterly, based on over the most recent quarter against which the 42 day can be applied (e.g. the December 2015 quarterly assessment will be based on the percentage of admitted patient episodes coded within 42 days of the episode separation for all episode separations dated between 1 July 2015 and 30 September 2015). 21

22 Service Agreement Key Performance Indicator s data collection Monthly. Data collected through Health Central from ipm on the sixth working day of the month (e.g. the December 2015 quarterly assessment for all episode separations dated between 1 July 2015 and 30 September 2015 will be based on data collected from Health Central through ipm on the sixth working day in January 2016). Admitted patient episode coding (clinical coding) including contracted care accuracy FA6 data collection This KPI measures the percentage of fatal data errors (as specified in the schedule below) that are corrected within 30 days of being reported by DHHS to the THS. At the end of each month, DHHS will provide THSs with a list of fatal data errors detected over the previous month. Errors not corrected by the THS within 30 days of receipt of the list will be considered to fail. The date of receipt will be considered to be the date upon which the list of fatal data errors is ed to THS CEO s by SPP. The list will clearly indicate the date by which the correction of fatal data errors is to occur. 100% within 30 days of advice. DHHS SPP. Quarterly, based on over the most recent quarter against which the 30 day can be applied (e.g. the December 2015 quarterly assessment will be based on the percentage of fatal data errors corrected within 30 days of receipt of the monthly list of fatal data errors for the months of July 2015, August 2015 and September 2015). Monthly. Data collected through Health Central from ipm on the sixth working day of the month (e.g. the December 2015 quarterly assessment for the months of July 2015, August 2015 and September 2015 will be based on data collected from Health Central through ipm on the sixth working day in January 2016). ipm. 22

23 Service Agreement Key Performance Indicator s Safety and Quality Hand Hygiene compliance SQ1 This KPI measures the compliance rate as the percentage of correct hand hygiene performed by hospital staff. Data is collected by authorised Hand Hygiene auditors in accordance with the Hand Hygiene Australia, Hand Hygiene Manual. Numerator: Number of times hand hygiene was performed correctly at the correct time. Denominator: Number of hand hygiene opportunities that were observed. 70%. An interim national benchmark of 70% for hand hygiene reporting on MyHospitals has been advised by the Australian Commission on Safety and Quality in Health Care. Facility specific: RHH, LGH, NWRH and MCH. Performance is assessed quarterly based on the most recent published TIPCU data. Data is submitted to Hand Hygiene Australia three times per annum: March 31 st June 30 th October 31 st. TIPCU. Healthcare associated staphylococcus aureus (including MRSA) bacteraemia infection rate SQ2 This KPI measures the rate of Healthcare Associated Staphylococcus aureus bacteraemia infection. This KPI is concerned with cases of this infection which are associated with a patient receiving healthcare. The definitions applied are consistent with national definitions which are published by the Australian Commission on Safety and Quality in Healthcare Data set specification Surveillance of Healthcare Associated Infections: Staphylococcus aureus bacteraemia and Clostridium difficile infection (Version 4.0). Numerator: Number of cases of healthcare associated Staphylococcus aureus bacteraemia. Denominator: Number of patient days for the given (matching the numerator ). 23

24 Service Agreement Key Performance Indicator s No more than 2.0 cases per 10,000 patient days. The national benchmark for states and territories (public hospitals) according to the Australian Commission on Safety and Quality in Health Care. Facility specific: RHH, LGH, NWRH and MCH. Performance is assessed quarterly based on the most recent published TIPCU data. In line with the TIPCU Staphylococcus aureus Bacteraemia Surveillance Protocol V3, 2011 data is collected and reported on as per the following process: TIPCU. TIPCU receive notification of a SAB from the Communicable Diseases Prevention Unit (CDPU). Participating hospitals will receive notification of a SAB from TIPCU and are requested to provide additional information via a SAB Surveillance Form. All SAB which were collected before the end of the month should have completed surveillance information submitted to TIPCU by the 10th calendar day of the following month or nearest work day. The TIPCU obtain a monthly summary report detailing all SABs from the participating laboratories. This data is used by TIPCU to validate that all forms received by the IC Teams and GPs correspond with the individual reports of SABs provided by the laboratories. Publically identified hospital data is published quarterly by the Tasmanian Infection & Control Unit and is available on the TIPCU DHHS website and used in SPP Quarterly Performance Reporting. Access to Care (Emergency Care and Elective Surgery) Percentage of Triage 1 emergency department presentations seen within the recommended time AEC1 This KPI measures the percentage of patients that are treated within the national recommended benchmark for waiting times for triage category 1 in public hospital emergency departments. The definitions applied are consistent with the national definitions used for reporting against the National Partnership Agreement on Hospital and Health Workforce Reform. The definitions include presentations that have been assigned a triage category between 1 and 5. Presentations that are did not wait, dead on arrival or the waiting time to service delivery is invalid are excluded for the purpose of calculating this KPI. See Australasian Triage Scale from the Australasian College for Emergency Medicine for a description of each triage category, including indicative clinical descriptors. Time to treatment is calculated by subtracting the date and time the patient presented to the emergency department from the date and time treatment 24

25 100%. Service Agreement Key Performance Indicator s commenced. The time to treatment is then compared to the recommended treatment time for the allocated initial triage category. The KPI is calculated for triage category 1 and presented as a percentage. Computation: 100 x (Numerator Denominator) Numerator: Total number of presentations to emergency departments that were treated within benchmarks for triage category 1: Triage category 1: seen within seconds, calculated as less than 2 minutes (being a waiting time of 2 or below, which allows for 2:59 seconds*). * This is in line with the national reporting standards. Denominator: Total number of triage 1 presentations to emergency departments. Australasian College for Emergency Medicine. Facility specific. RHH, LGH, NWRH and MCH. Performance is assessed quarterly. A new assessment commences at the beginning of each quarter (i.e. is not measured on a year to date basis). Monthly. Data collected through Health Central from ipm on the sixth working day of the month. EDIS. Percentage of Triage 2 emergency department presentations seen within the recommended time AEC2 This KPI measures the percentage of patients that are treated within the national recommended benchmark for waiting times for triage category 2 in public hospital emergency departments. The definitions applied are consistent with the national definitions used for reporting against the National Partnership Agreement on Hospital and Health Workforce Reform. The definitions include presentations that have been assigned a triage category between 1 and 5. Presentations that are did not wait, dead on arrival or the waiting time to service delivery is invalid are excluded for the purpose of calculating this KPI. See Australasian Triage Scale from the Australasian College for Emergency Medicine for a description of each triage category, including indicative clinical descriptors. Time to treatment is calculated by subtracting the date and time the patient presented to the emergency department from the date and time treatment commenced. The time to treatment is then compared to the recommended treatment time for the allocated initial triage category. The KPI is calculated for triage category 2 and presented as a percentage. 25

26 Computation: 100 x (Numerator Denominator) Service Agreement Key Performance Indicator s Numerator: Total number of presentations to emergency departments that were treated within benchmarks for triage category 2: Triage category 2: seen within 10 minutes (being a waiting time of 10 or below, which allows for 10:59 seconds*). * This is in line with the national reporting standards. Denominator: Total number of triage 2 presentations to emergency departments. 80%. Australasian College for Emergency Medicine. Facility specific. RHH, LGH, NWRH and MCH. Performance is assessed quarterly. A new assessment commences at the beginning of each quarter (i.e. is not measured on a year to date basis). Monthly. Data collected through Health Central from ipm on the sixth working day of the month. EDIS. Percentage of emergency department did not wait presentations AEC3 This KPI measures the percentage of emergency department presentations that concluded with the patient leaving the emergency department before being attended by a health care professional. The definitions applied were set by the Emergency Care Network Steering Committee. The definitions include presentations that have been assigned a triage category between 1 and 5. Presentations that are dead on arrival or the waiting time to service delivery is invalid are excluded for the purpose of calculating this KPI. See Australasian Triage Scale from the Australasian College for Emergency Medicine for a description of each triage category, including indicative clinical descriptors. The KPI is presented as a percentage. Numerator: Total number of presentations who have been identified as did not wait. Denominator: Total number of presentations to emergency departments. </= 5%. Level Emergency Care Network Steering Committee. Facility specific. RHH, LGH, NWRH and MCH. 26

27 Service Agreement Key Performance Indicator s Performance is assessed quarterly. A new assessment commences at the beginning of each quarter (i.e. is not measured on a year to date basis). Monthly. Data collected through Health Central from ipm on the sixth working day of the month. EDIS. Time until most admitted patients (90%) departed emergency department AEC4 Level and assessment This KPI measures the time within which 90% of patients were admitted and physically left the emergency department. Numerator: include records with the triage categories from 1 to 5. exclude records if the Waiting time to service is invalid, i.e. - Length of stay < 0. - Presentation date or time is missing. - Physical departure date or time is missing. The 90th percentile (the ninetieth percentage value in a group of data arranged from lowest to highest value for time waited) represents the time within which 90% of patients were admitted and physically left the emergency department. For example, if there were 100 observations admitted to the hospital, the 90th percentile will correspond to the average time for the 90th and 91st observations. If there were 101 observations, the 90th percentile will correspond to the time for the 91st observation. Emergency department stay time is calculated by subtracting the date and time the patient presented to the emergency department from the date and time the patient physically left the emergency department. Denominator: Not applicable. </= 8 hours. National Health Performance Authority. Facility specific. RHH, LGH, NWRH and MCH. Performance is assessed quarterly. A new assessment commences at the beginning of each quarter (i.e. is not measured on a year to date basis). Monthly. Data collected through Health Central from ipm on the sixth working day of the month. 27

28 Service Agreement Key Performance Indicator s EDIS. Ambulance offload delay part 1 AEC5 This KPI measures the percentage of Ambulance Tasmania presentations to an emergency department for which transfer of clinical care to the emergency department occurs within the Australasian College for Emergency Medicine recommended target times (see below). This KPI is measured as a percentage. The definitions applied were recommended by the Australasian College for Emergency Medicine. The definitions include presentations that have been assigned a triage category between 1 and 5. Presentations that are 'dead on arrival' are excluded for the purpose of calculating this KPI. The definition includes presentations that arrive by Ambulance Tasmania (arrival modes such as police, nonemergency patient transport are out of scope). Numerator: Total number of Ambulance Tasmania presentations to an emergency department where transfer of clinical care to the emergency department occurred within the following target times: 85% of presentations transferred within 15 minutes. 100% of presentations transferred within 30 minutes. Denominator: Total number of Ambulance Tasmania presentations to the emergency department. 85% within 15 minutes. Level Australasian College for Emergency Medicine. Facility specific. RHH, LGH, NWRH and MCH. Performance is assessed quarterly. A new assessment commences at the beginning of each quarter (i.e. is not measured on a year to date basis). Monthly. Data collected through Health Central from ipm on the sixth working day of the month. EDIS. Ambulance offload delay part 2 AEC6 This KPI measures the percentage of Ambulance Tasmania presentations to an emergency department for which transfer of clinical care to the emergency department occurs within the Australasian College for Emergency Medicine recommended target times (see below). This KPI is measured as a percentage. The definitions applied were recommended by the Australasian College for Emergency Medicine. The definitions include presentations that have been assigned a 28

29 Service Agreement Key Performance Indicator s triage category between 1 and 5. Presentations that are 'dead on arrival' are excluded for the purpose of calculating this KPI. The definition includes presentations that arrive by Ambulance Tasmania (arrival modes such as police, nonemergency patient transport are out of scope). Numerator: Total number of Ambulance Tasmania presentations to an emergency department where transfer of clinical care to the emergency department occurred within the following target times: 85% of presentations transferred within 15 minutes. 100% of presentations transferred within 30 minutes. Denominator: Total number of Ambulance Tasmania presentations to the emergency department. 100% within 30 minutes. Australasian College for Emergency Medicine. Facility specific. RHH, LGH, NWRH and MCH. Performance is assessed quarterly. A new assessment commences at the beginning of each quarter (i.e. is not measured on a year to date basis). Monthly. Data collected through Health Central from ipm on the sixth working day of the month. EDIS. Access to Elective Surgery Baseline elective surgery admissions AES1a This KPI measures the total number of admissions for elective surgery from the elective surgery wait list, excluding activity funded under the Rebuilding Health Services (RHS) program, and the Tasmanian Health Assistance Package (THAP). Count of admissions for surgery where the removal reason is Planned Procedure Completed or Admitted as emergency, and the funding is Regular. Baseline elective surgery admissions: DHHS SPP. Performance is assessed quarterly on a year-to-date basis. Monthly. Data collected through Health Central from ipm. ipm. 29

30 Service Agreement Key Performance Indicator s Rebuilding Health Services AES1b This KPI measures elective surgery which is funded under the Rebuilding Health Services (RHS) program. Count of admissions for surgery where the funding is RHS and where the removal reason is Planned Procedure Completed or Admitted as emergency. Number of admissions: DHHS SPP. Performance is assessed quarterly on a year-to-date basis. Monthly. Data collected through Health Central from ipm. ipm. Tasmanian Health Assistant Package admissions AES1c This KPI measure activity funded under the Tasmanian Health Assistance Package (THAP). Count of admissions for elective surgery where the funding is THAP and where the removal reason is Planned Procedure Completed or Admitted as emergency. Number of THAP funded admissions: DHHS SPP. Performance is assessed quarterly on a year-to-date basis. Monthly. Data collected through Health Central from ipm. ipm. Average overdue days AES2 This KPI measures the average number of overdue days waiting of patients who have waited beyond the clinically recommended time. Numerator: count of the total number of overdue days waiting for all patients. Denominator: the number of patients who have waited beyond the clinically recommended time. December 2015: 177. June 2016:

31 Service Agreement Key Performance Indicator s DHHS SPP. Performance is assessed 6 monthly as at the end of the. A new assessment commences at the beginning of each six month (i.e. is not measured on a year to date basis). Monthly. Data collected through Health Central from ipm. ipm. Maximum wait time AES3 This KPI measures the maximum waiting time for patients who are on the elective surgery list waiting for a surgical procedure. The number of days waiting for the longest waiting patient on the elective surgery waiting list. December 2015: 730. June 2016: 600. DHHS SPP. Performance is assessed 6 monthly as at the end of the. A new assessment commences at the beginning of each six month (i.e. is not measured on a year to date basis). Monthly. Data collected through Health Central from ipm. ipm. Category 1 admitted within the recommended time AES4 This KPI measures the number of Category 1 patients who are admitted for surgery within the clinically recommended timeframe of 30 days. This KPI is expressed as a percentage. Numerator: Total number of Category 1 patients admitted within the clinically recommended time of 30 days or less, where the removal reason is Planned Procedure Completed or Admitted as emergency. Denominator: Total number admissions for Category 1 patients where the removal reason is Planned Procedure Completed or Admitted as emergency. December 2015: 80%. June 2016: 90%. DHHS SPP. 31

32 Service Agreement Key Performance Indicator s Performance is assessed 6 monthly. A new assessment commences at the beginning of each six month (i.e. is not measured on a year to date basis). Monthly. Data collected through Health Central from ipm. ipm. Category 2 admitted within the recommended time AES5 This KPI measures the number of Category 2 patients who are admitted for surgery within the clinically recommended time of 90 days. This KPI is expressed as a percentage. Numerator: Total number of Category 2 patients removed from the wait list within the clinically recommended time of 90 days or less, where the removal reason is Planned Procedure Completed or Admitted as emergency. Denominator: Total number admissions for Category 2 patients where the removal reason is Planned Procedure Completed or Admitted as emergency. December 2015: 60%. June 2016: 70%. DHHS SPP. Performance is assessed 6 monthly. A new assessment commences at the beginning of each six month (i.e. is not measured on a year to date basis). Monthly. Data collected through Health Central from ipm. ipm. Category 3 admitted within the recommended time AES6 This KPI will measure number of Category 3 patients who are admitted for surgery within the clinically recommended timeframe of 365 days. This KPI is expressed as a percentage. Numerator: Total number of Category 3 patients removed from the wait list within the clinically recommended time of 365 days or less, where the removal reason is Planned Procedure Completed or Admitted as emergency. Denominator: Total number admissions for Category 3 patients where the removal reason is Planned Procedure Completed or Admitted as emergency. December 2015: 60%. 32